We’re doing medical training wrong

I’m old. OK, not “old” old, but old enough that, well, for example: IMG_0966We were at a friend’s birthday party the other night (she called it a “quinceañera plus 35”) and as it got late I said, “well, we have to go send the baby sitter home.” A guy across the table looked at me, and after a few seconds said, “I’m a grandpa.”

Anyway, here I am, twenty years after medical school graduation, and what I see is that medical training and hospital life have changed very little. I’ve been following a twitter feed of medical professionals sharing their stories, the ones we can’t tell our families (the implications of which requires its own post). The stories are all familiar. What comes through is that these people who we count on to care for us and our families are not OK.

We have these debates about resident work hour restrictions, education vs. service, etc., and we are clearly insane (also more on this below).

This morning I went for a walk/run with a friend. Spring has been notably absent, but is peeking out at us today, so we took to the trail. A few years ago he had major heart surgery. Me, I’ve been married, had a daughter, divorced, and since have found a best friend to marry and gained another daughter. This weekend we lost our dog, a dog that had been with her through too many things to mention. Life continues.

Life is real. Why are we debating how much torture is too much for our future doctors? Those of us who have endured medical training have all sorts of excuses: it’s how you learn to make the hard decisions, it mirrors your future career, sleep depravation will happen so better get used to it. It’s all bullshit.

All the minutiae (continuity of care, handoffs, hour restrictions) are all just ways of squeezing a balloon full of pain, sending it to one end until it’s near bursting, then to the other, and back again. We have a doctor shortage in this country, especially primary care physicians like me. Here’s how we change that.

A Modest Proposal

There is scientific literature on medical training, and from other fields, on fatigue, safety, and performance. We need to use it. Fatigue kills. Checklists save lives. It’s all pretty basic.

We need more data on why American medical grads shun primary care, but we can make some pretty safe conjectures. First, undergrad and medical school debt is crushing, and primary care isn’t the smartest way to pay it off. Second, much of our medical training takes place at academic tertiary care centers where specialty care is highly valued. Doctors “in the community” are simply the source of our patients. We don’t value them.

Here’s what we need to do. First, medical education needs to be fully subsidized with some or all students paying no tuition. In return they will have to serve the community after school. This service requirement should be meaningful to the community but not onerous for the doctor, say a year somewhere in the country that needs doctors. One model would be to have permanent clinics where they are needed (underserved urban and rural areas), and have them staffed by new medical graduates, supervised by a permanent but small staff of senior doctors. These new doctors would be given housing and a reasonable stipend. After they’ve served their year, they can start their residencies.  Then they can go about their career without worrying about how to pay off crushing debt for decades. It’s a win-win. Some of these doctors might want to stay at these clinics. Great. We’ll find a way to finish training them and they can become the senior staff at these public health clinics.

Specialists salaries, which contrary to popular belief are not the major driver of health care costs, would probably be able to drop a little if doctors weren’t as concerned about debt. It might change the entire look of the medical profession viz proportion of specialists to generalists.

All this would allow us to make training more humane by lengthening it. Internal medicine is a three year residency, which feels about right [citation needed]. But since we need to make it more safe and humane, we need to cut duty hours. If we cut duty hours, then we need more time to learn. A four year IM residency without abusive duty hours would allow for full training, and since the residents wouldn’t have much debt, there isn’t the same hurry to get specialty training and start working.

These ideas require data. How much training is adequate for each specialty? What work hours are safe? What are the probable consequences of adding two years to training (the service and the extra training year)? Would this change allow a shortening of medical school from four years to three?

It’s been over a century since the Flexner report reformed medical education. We need a new, data-driven Flexner report, one that sets evidence-based goals consistent with our values and our needs as a society. It’s a big job, but the cost of inaction is quite steep.